Multiple media outlets, including Vox, have reported the terrifying statistics: The opioid epidemic has led to the deadliest drug crisis in US history — deadlier than the crack epidemic of the 1980s and 1990s. Drug overdoses now cause more deaths than gun violence and car crashes. They even caused more deaths in 2015 than HIV/AIDS did at the height of the epidemic in 1995.
A new study, however, suggests that we may be in fact underestimating the death toll of the opioid epidemic and current drug crisis. And we don’t even know by how much.
The study, conducted by researchers at the Centers for Disease Control and Prevention, looked at 1,676 deaths in Minnesota’s Unexplained Death surveillance system (UNEX) from 2006 to 2015. This system is meant to refer cases with no clear cause of death to further testing and analysis.
In total, 59 of the UNEX deaths, or about 3.5 percent, were linked to opioids. But more than half of these opioid-linked deaths didn’t show up in Minnesota’s official total for opioid overdose deaths.
Given that this is just one death surveillance system in a state that only had a bit more than 300 reported opioid overdose deaths in 2015, it’s possible that these dozens of deaths speak to a much bigger problem of undercounting the opioid epidemic nationwide. It’s unclear just how widespread of a problem this is in other death surveillance systems and other states, but the study’s findings suggest that the numbers we have so far for opioid overdose deaths are at best a minimum.
In other words, the US’s deadliest drug overdose crisis in history is likely even deadlier than we think.
Local officials make the call on whether a death was caused by an overdose — and they can be wrong
Typically, deaths are marked by local coroners or medical examiners through a system made up of codes from the International Classification of Diseases, 10th Edition (ICD-10). If a medical examiner marks a death as immediately caused by an opioid overdose through the proper ICD-10 codes, that death is eventually added to the US’s total for opioid overdose deaths.
But there’s no national standard for what counts as an opioid overdose, so it’s left to local medical officials to decide whether a death was caused by an overdose or not. This can get surprisingly tricky — particularly in cases involving multiple conditions or for cases in which someone’s death seemed to be immediately caused by one condition but that condition had a separate underlying medical issue behind it. (And in cases in which local medical officials, some of whom are elected, aren’t really qualified for the job.)
For instance, opioids are believed to increase the risk of pneumonia. But if a medical examiner sees that a person died of pneumonia, they might mark the death as caused by pneumonia, even if opioids were the underlying cause for the death. (This would be a bit like blaming a lifetime smoker’s death on lung cancer without acknowledging the cigarettes’ contribution.)
Victoria Hall, one of the study’s authors, gave a real-world example of this while presenting her findings at the Epidemic Intelligence Service Conference on Monday.
“In early spring, the Minnesota Department of Health was notified of an unexplained death: a middle-aged man who died suddenly at home,” Hall said. “He was on long- term opioid therapy for some back pain, and his family was a little bit concerned that he was abusing his medication.”
She added, “On autopsy, the medical examiner was quite concerned about pneumonia in this case, and that’s how the case was referred to the Minnesota Department of Health unexplained deaths program. Further testing diagnosed an influenza pneumonia, but also detected a toxic level of opioids in his system. However, on the death certificate, it only listed the pneumonia and made no mention of opioids.”
Since this is just one study of one surveillance system in one state, it’s unclear just how widespread this kind of underreporting is in the US. But the data suggests that there is at least some undercounting going on — which is especially worrying, given that this is already the deadliest drug overdose crisis in US history.
“It does seem like it is almost an iceberg of an epidemic,” Hall said. “We already know that it’s bad. And while my research can’t speak to what percent we’re underestimating, we know we are missing some cases.”
The opioid epidemic, explained in fewer than 600 words
In 2015, more Americans died of drug overdoses than any other year on record — more than 52,000 deaths in just one year. That's higher than the more than 38,000 who died in car crashes, the more than 36,000 who died from gun violence, and the more than 43,000 who died due to HIV/AIDS during that epidemic's peak in 1995.
This latest drug epidemic, however, is not solely about illegal drugs. It began, in fact, with a legal drug.
Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There's a good reason for that: About one in three Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine.
Pharmaceutical companies took advantage of this concern. Through a big marketing campaign, they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term, chronic pain is very weak (despite their effectiveness for short-term, acute pain), while the evidence that opioids cause harm in the long term is very strong.
So painkillers proliferated, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.
As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (typically prescribed to relieve anxiety). By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths.
Seeing the rise in opioid misuse and deaths, officials have cracked down on prescriptions painkillers. Law enforcement, for instance, threatened doctors with incarceration and the loss of their medical licenses if they prescribed the drugs unscrupulously.
Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. Doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.
Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids: heroin and fentanyl, a synthetic opioid that's often manufactured illegally for non-medical uses.
Not all painkiller users went this way, and not all opioid users started with painkillers. But statistics suggest many did: A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.
So other types of opioid overdoses, excluding painkillers, also rose.
That doesn't mean cracking down on painkillers was a mistake. It appeared to slow the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders.
But the likely solution is to get opioid users into treatment. According to 2014 federal data, at least 89 percent of people who met the definition for a drug use disorder didn't get treatment. Patients with drug use disorders also often complain of weeks- or months-long waiting periods for care.
So federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and Suboxone.
Some states, like Louisiana and Indiana, have taken a "tough on crime" approach that focuses on incarcerating drug traffickers. But the incarceration approach has been around for decades — and it hasn’t stopped massive drug epidemics like the current crisis.